Contrary to everything scientists might have feared exposing their irrationality, their humanity, even their craftiness and hot tempers, makes the public more receptive to the revelations of science, not less. People can not only take the truth about science, they actually prefer it.

]]>Placebo precisionSat, 14 Mar 2015 00:00:00 -0700http://www.sciencebasedmedicine.org/placebo-are-you-there/
https://www.painscience.com/microblog/placebo-precision.htmlHarriet Hall translated a French article on placebo by Jean Brissonnet for ScienceBasedMedicine.org, calling it “the best explanation of placebo that I had ever read.” (I was quite involved editorially, and in particular spent a bunch of time on producing shinier, translated diagrams.) I’m not quite sure it’s the best placebo explanation I’ve ever read, but on the other hand I can’t point to a better one, and it is certainly chock-a-block with historical context, effectively cited science, and little gems of clarity on this tricky topic. For example:

There are many arguments against its use in healthcare practice. Do we have the right to fool the patient? Do we have the right to act without his consent? Can we risk permanently damaging the doctor/patient relationship if the patient finds out that he has been deceived? A better understanding of the phenomenon makes such questions obsolete. To the extent that the “placebo effect” is only a contextual effect that doesn’t depend on the use of an inactive object, it can and should be used in healthcare practice. It can probably be used instead of a prescription in certain functional diseases, and it certainly can potentiate the effect of prescribed drugs in many cases.

The gist of the article is that what we usually refer to as “the” placebo effect is a category of phenomena, many of them clinically meaningless, and we truly need to learn and use more precise terminology. It’s not just word-nerd nitpickery! Speaking only of “placebo” is about as useful as saying only “furniture” when you mean “chaise longue” or “credenza” or “futon.”

]]>Does swearing reduce pain?Fri, 13 Mar 2015 00:00:01 -0700http://www.ncbi.nlm.nih.gov/pubmed/19590391
https://www.painscience.com/microblog/does-swearing-reduce-pain.htmlDoes swearing reduce pain? @^#@%, yeah! And so does saying “ow!” according to a new study. And of course it’s not really surprising, given what we know about pain (it’s weird and thoroughly brain-tuned). It probably doesn’t have much relevance to chronic pain. But it’s interesting, and fun.

In our study, saying “ow” increased pain tolerance by about 20%. One may speculate that benefits in real life may, perhaps, even be larger. There, vocalisations are typically less measured. That is, people are likely to say “ow” and other things more forcefully and can do so continuously without the somewhat unnatural breaks that were introduced for standardisation in our study.

]]>Insider view of naturopathic trainingFri, 13 Mar 2015 00:00:00 -0700http://www.sciencebasedmedicine.org/nd-confession-part-1-clinical-training-inside-and-out/
https://www.painscience.com/microblog/insider-view-of-naturopathic-training.htmlNaturopathic doctor training does not hold a candle to medical training, as I’ve explained before (see Chiropractor, Naturopath Training Way Less Than Doctors). It’s nice to have some insider confirmation of that now. Britt Marie Hermes is a naturopathy apostate, and she’s telling her story on her own new blog, NaturopathicDiaries.com and in a new series of guest posts on ScienceBasedMedicine.org, starting with an exposé of her training (which I was particularly proud to help publish). It’s cringe-inducing.

Given my journey through naturopathic medical school, I can provide strong evidence and testimony of the quality and quantity of training at Bastyr University. I base what follows on my academic transcript, course syllabi, course catalog, and the student clinician’s handbook in addition to my personal experiences. It should come as no surprise to readers of ScienceBasedMedicine.org that naturopathic training is not as the profession presents. I’ll say it anyway: naturopathic education is riddled with pseudoscience, debunked medical theories, and experimental medical practices.

]]>Apt analogyWed, 11 Mar 2015 00:00:03 -0700http://www.massage-stlouis.com/nociception-and-pain-what-difference-and-why-does-it-matter
https://www.painscience.com/microblog/apt-analogy.htmlAlice Sanvito, massage therapist, in a new article about the difference between nociception and pain:

When we live with chronic pain, it can dominate our lives and dramatically alter the way we live, like an obnoxious cab driver who insists on taking us where HE wants to go rather than where WE want to go.

]]>Googling symptomsWed, 11 Mar 2015 00:00:02 -0700https://www.painscience.com/microblog/googling-symptoms.htmlGoogling your symptoms is as unavoidable as it is unwise. We almost literally cannot help ourselves. I imagine there is a modern epidemic of reckless, panicky self-treatment based on really bad Internet-powered self-diagnosis — something I am acutely aware of every time I hit my magic “publish” button. (With great power…)

The Flemish government is acutely aware of it too, which is why they commissioned a couple of (hilarious) public service announcements about it, one that’s pure sketch comedy, and one about their clever delivery method: the clever monkeys used Google’s own advertising program to target people searching for common symptoms!

Confession: reading about many kinds of symptoms actually makes me swoon. I get dizzy and queasy. It’s not really a hypochondriac effect — I don’t really start worrying about having the symptoms. It’s more like the way some people can’t handle the sight of blood. I just can’t handle the idea of many symptoms.

Laura Allen’s book is unique. As far as I know, she is the first massage therapist to ever write one like it: a scathing and sassy denunciation of her profession’s love affair with crystals, chakras, and fringe science. Addressing her colleagues throughout, she tells them, “Our profession has turned into the snake oil medicine show.”

My review copy. Click to buy on Amazon.

The book takes the reader on a tour of most of the weird practices that seem to cling to massage therapy like parasites, and asks again and again, “Excuse me, exactly how does that work?” In most cases, of course, the point is that they don’t.

And she describes her own “reformation” from believer to skeptic. She once believed everything she’s rolling her eyes at today. All her snark has a self-depractory poignancy to it, and I hope it makes her sharp criticisms palatable and funny to many people who wouldn’t be able to hear it from anyone else. Allen used to believe it all! “I could not possibly even name all the things I went through,” she writes, but her effort is impressive, and it puts my own substantial New Age dabblings in the 90s to shame. Here’s a sample of how far down the rabbit hole Laura Allen went:

I had a lot of psychic readings. I tried Aura Soma, which is described as “color healing.” I got tuned up with tuning forks, and crystal bowls. I participated in one workshop called Matterspeak, which consisted of sitting around chanting random words, letters, and numbers for 8 hours, as in “1263supercalifragilisti789.” I don’t remember what the purpose of that was and frankly doubt that it had any purpose, other than to enrich the teacher’s pocketbook. If memory serves, she had “channeled” that information from the Atlanteans. I also used the chi machines, the detox foot baths and pads, biofeedback and all kinds of computer programs designed to balance your body, mind and spirit, and most New Agey-sounding things in existence at the time. If it was out there, I tried it.

While we were on a road trip out west, I collected some buffalo dung—I actually witnessed the buffalo relieving himself, waited until he ambled off, and I jumped out of the car with a zip-lock bag to harvest it for future ceremonial purposes. Since it had come from a buffalo on the reservation I figured it was more powerful than your average cow dung.

Allen’s book is all about a different sort of powerful bullshit:

People like to have something to believe in, don’t they? Whether it’s religion, the tooth fairy, or the efficacy of something they have bought—and bought into—people get attached to their BS. I like to say that BS can stand for “belief system” or “bullshit”—your call.

Massage therapists, and others in the holistic arts, are no exception. We seem to be a particularly gullible bunch. And there are a lot of people who have seized upon that, and marketed their products, their classes, their modalities, and their wild claims to us...and many of us have fallen for it, hook, line and sinker...and unfortunately, gone on to convince our clients to buy into it, as well.

Fortunately, not all beliefs are firmly held. Many massage therapists come into them rather carelessly (as I did) — they just seem to go with the territory. Laura Allen’s book is a friendly kick in the rump for any massage therapist teetering on the brink of coming to her senses.

So quotable!

I’ve harvested several quotes from Laura’s book, and they will appear here and there around PainScience.com from now on. It is invaluable to cite her irreverent voice and vast experience with the massage profession — of which she is still a vital member. You’ll find her quoted in the following articles for now:

]]>Sex and back painFri, 06 Mar 2015 00:00:00 -0700https://www.painscience.com/microblog/sex-and-back-pain.htmlSexy question from a back pain patient:

I seem to be able to handle more exercise when the exercise is sex, as opposed to working out. Is there any research on why this might be so? Happy chemicals canceling out the pain chemicals?

No research that I know of. (It’s hard to compare sex to a placebo.) I wouldn’t say so much happy “chemicals” specifically cancelling out pain as just the happy cancelling out the pain. Sex is absurdly uplifting, and mood is a well-known mediator of pain (plenty of research about that).

Pain is a motivator. It exists to get us to act. We hurt when our brains think we need to do something differently for safety, if possible. Our brains are willing to “mute” many danger signals for the sake of sex… because it’s worth it, baby. “Muting” is technically called descending inhibition, which Todd Hargrove describes like this in his excellent book, A Guide to Better Movement:

…the brain does not want to discourage the activity that is creating the nociception, and therefore decides to simply block the danger signals. Descending inhibition may be the mechanism that explains why many people do not feel pain from degenerative changes in joints, bulging discs, or torn rotator cuffs. It also likely explains why pain is often not felt during an emergency.

]]>A literally stiff backThu, 05 Mar 2015 00:00:00 -0700https://www.painscience.com/microblog/literally-stiff-back.htmlSometimes the sacrum is fused to the lowest lumbar vertebra: a lumbosacral transition vertebra. “LSTV is the most common congenital anomaly of the lumbosacral spine.” In about a thousand patients studied by Sekharappa et al, it was about twice as common in patients who had sought spinal surgery as it was in patients with no spinal complaint (about 14-16% of patients, instead of 8%). The study also identified a “definite causal relationship” with degeneration of the disc above the LSTV.

Fusion of the sacroiliac joint is closely related and even more common, as high as half the population by the age of 80, and freakishly more common in men than women for some reason, in 287 subjects studied by Dar et al.

These joints — the lumbosacral, and the sacroiliac — are so sturdy and immobile that, in some people, they cross the line and develop into a solid block. Talk about a stiff back! Literally!

]]>Video of weirdly rippling muscleWed, 04 Mar 2015 00:00:00 -0700https://www.youtube.com/watch?v=RicWrvozUsQ
https://www.painscience.com/microblog/video-of-weirdly-rippling-muscle.htmlThis is a video of a nifty muscle rippling phenomenon. I’ve waited for an opportunity to film it in my own quadriceps, where I have seen it a few times, but it’s hard enough to induce that I haven’t had a chance yet. Hat tip to reader Chris for finding this video of it:

That’s very similar to what I’ve seen in my own muscles, but much more languid. It’s always been at least triple that speed in my flesh! Could just be natural variation in the phenomenon, or something else altogether, but this definitely looks more like it than anything else I’ve seen.

]]>Nerve root wiggle roomMon, 02 Mar 2015 00:00:00 -0700https://www.painscience.com/microblog/nerve-root-wiggle-room.htmlFunny how tricky it can be to find a citation to confirm something relatively obvious. In this case, I’ve been aware for many years that nerve roots have a lot of “wiggle room” where they pass through their holes in the spine. This is a useful fact for reassuring people that “nerve pinches” are unusual. It’s come up in my reading many times over the years, and I’ve seen many anatomical drawings and dissection videos and so on, but … citation needed, right? I try to check all my assumptions.

When I set to “proving” what I know with a citation to a scientific paper, I had some trouble! It was hard data to find for some reason, and the paper I finally found, Torun et al kicks off by confirming that impression: “There have been few anatomic studies on the foramina and roots of the lumbar region….” Indeed. And that’s in a 2006 paper! Hardly ancient.

However, what I knew was confirmed. The holes between the (lumbar) vertebrae that the nerve roots pass through can be more than a couple centimetres wide, while the nerve roots themselves are only about 3-4mm thick. I made a diagram:

Schematic of nerve root wiggle room

On the left are the rough proportions of a healthy nerve root and the hole it passes through (intervertebral foramen). I also found some simple data on how the holes change shape during spinal traction and compression (Sari et al, Takasaki et al): they get a little larger or smaller, as shown on the right…but there’s still lots of nerve root room.

]]>IT band plungeringFri, 27 Feb 2015 00:00:00 -0700https://www.painscience.com/microblog/it-band-plungering.htmlIf it’s stuck, suck it? In this poor quality video we see a physical therapist using a cute little toilet plunger — for a hobbit loo? — to “suck” the iliotibial band off the leg. To achieve an IT band “release”, of course! (Arg, that blasted word!)

I think this is silly. Sure, it’s easy to see the suck-up-the-stuck-tissue “logic” of it, but it’s at odds with well-known IT band anatomy (the IT band is firmly anchored to the femur for most of it’s length), and it’s at odds with the nature of IT band syndrome (it doesn’t hurt because of “adherence of the IT band to the tissues beneath it”).

Even if the IT band did get stuck to underlying tissues, I’m not so sure that baby plunger would be helpful. It might lift some skin! The mechanics of it would work something like this experiment: (1) put a cookie sheet on the floor, (2) cover it with Saran Wrap, and then (3) try to pick up the cookie sheet with a toilet plunger, through the plastic. Good luck with that. (And you know what? It probably doesn’t even matter if you move that cookie sheet.)

This treatment idea is mostly just good for a chuckle. I’m sure it’s harmless to everything but your wallet … but also pointless. It boils down to a weird form of massage.

My book about iliotibial band syndrome has been updated with this vital information. (Sometimes book updates are high priority science. And sometimes they just fall in my lap and make me snicker and I can’t resist ‘em.)

You may have heard some of the buzz about the conference on social media. The conference definitely had a very buzzy feel to it, kind of Woodstockish, as if something important was happening, and Mr. Jones didn’t know what it was.

I’ve never felt more like I was missing an event I belonged at. But I’m a private, bookish recluse by nature and as poor a traveller as there ever was. When I travel, I do not sleep! (Some people probably scoff at that excuse. People who don’t know insomnia. And would be crushed by it if they did. Or perhaps the scoffers are just way, way more badass and resilient than me — maybe there’s some like that too.)

]]>Are experimental injection treatments “worth a try”?Mon, 23 Feb 2015 00:00:00 -0700https://www.painscience.com/microblog/are-experimental-injection-treatments-worth-a-try.htmlRarely. The bar for “worth a try” is fairly high for invasive treatments. Even “minimally” invasive ones like injections should only be considered when at least their safety is established (and it rarely is). What you really need is clear, consistent evidence of non-trivial benefit across several good trials before anything injected is “worth a try.” Before that it’s more like “hey, it’s your knee, don’t stab it”!

Of course, what’s worth trying is always a very personal decision, because it’s as much about risk tolerance and desperation levels as it is about the treatment. But my point is that almost everyone should be wary of needles filled with mysterious meds. For an example, see Does Platelet-Rich Plasma Injection Work?

]]>Free safety lesson! Is it safe to roll your head in a full circle?Wed, 18 Feb 2015 00:00:00 -0700https://www.painscience.com/microblog/free-safety-lesson-is-it-safe-to-roll-your-head-in-a-full-circle.htmlSo I was doing my daily mobilizations by the seaside, enjoying a winter sunset, and an elderly Chinese man walked by me. Then he turned, and said:

Excuse me, but I’m concerned that you are hurting your neck doing that. May I show you how to do it properly?

How extraordinary! What was I doing that was so hazardous that a total stranger would offer me free safety advice?

I was rolling my head in a full circle. Pretty alarming stuff.

Near English Bay, downtown Vancouver, Canada…scene of the free advice.

Many people believe that this is a problem, probably because it can be a bit crunchy (noisy). I’ve heard many warnings about it in exercise classes of all kinds over the years. The usually under-explained and vague rationale for avoiding rotation the neck is the idea that this is somehow unusually stressful for the neck joints. Supposedly it’s safer to stick to the cardinal planes of movement, or at least avoiding full extension.

I cannot think of any reason why: as long as it’s reasonably comfortable, there’s no problem. The cervical spine is generally just as well-built for compound movement as a ball-and-socket joint. I prefer to get the benefits of thoroughly moving my neck, and to avoid worrying about extremely trivial biomechanical hazards.

I politely refused the assistance. He stared at me like I was a bit nuts to refuse a safety lesson, and moved on. An odd incident.

I’ve updated my neck pain book with this little story, and a bit more detail.

]]>There are no guiltless factionsMon, 16 Feb 2015 00:00:01 -0700https://www.painscience.com/microblog/there-are-no-guiltless-factions.htmlThere are a lot of ideological factions in health care. Even my relatively small area of interest — musculoskeletal medicine and pain science — is amazingly factionalized. Sometimes it’s really hammered home when I get email from friends trash talking each other, both trying to recruit me, even while they are being very polite to each other publicly.

The longer I do this job, and the more incidents like that I observe, the more I believe that there are no guiltless factions — everyone is getting some stuff right, and some stuff wrong, and treating some ideas fairly and giving others short shrift. It just seems to be how human minds work. Confirmation bias everywhere!

Don’t get me wrong, though: some people are still a lot more wrong than others.

]]>Flesh still relevantMon, 16 Feb 2015 00:00:00 -0700https://www.painscience.com/microblog/flesh-still-relevant.htmlModern pain science is largely concerned with the role of the nervous system — pain is an “output of the brain,” a generated experience, and does not reside “in” the flesh. This perspective has yielded many priceless insights into how pain works (and how weird it is). But …

But it’s not the whole picture, of course, and we will never grok pain solely in terms of neurology. The nervous system is dazzling, but let’s not forget that it’s stacked on top of much older and richly functional bio “tech”: cellular biology is just as dazzling in its own way. The nervous system itself is just an extraordinary organization of cellular biology into something greater than the sum of its parts: every stitch of it is still ultimately relying on the dance of enzymes and ions and hormones. Synapses are just short range hormonal communication. It’s all just more cell tricks, spectacularly organized chemistry.

In short, the flesh and its failings are still important parts of how pain works.

But conflicts of interest are always interesting. I recently came across a paper that concluded that slight dehydration has important effects on mood and cognition (Armstrong). I was taking it seriously for a few minutes until I discovered that it was funded in part by a giant corporation that sells bottled water, which made me roll my eyes and get a lot less interested in the results (which were minor anyway, I thought).

So now what to believe? Who knows: the data may be perfectly good, or hopelessly corrupted. We just can’t tell without more information. We’ll simply never know what’s true without more research…which will probably be hard to get anyone but another water bottling company to pay for!

]]>Flabbergasted by the fabellaMon, 09 Feb 2015 00:00:00 -0700https://www.painscience.com/microblog/flabbergasted-by-the-fabella.htmlHow did I not know about this? After a good solid decade of reading regularly and widely about knee pain, I am flabbergasted that I had never heard of the fabella.

Some folks have an extra knee bone, a sort of second kneecap in back — the f-for fabella instead of the p-for-patella — embedded in the tendon of the gastrocnemius muscle.

How many people have this osseous oddity? Apparently it’s not clear. Driessen et al: “The presence of the fabella in humans varies widely and is reported in the literature to range from 20% to 87%.” That’s quite a range!

It may form for the same reason the patella is there (leverage, high stresses), and it can get to hurting just like the patella (fabella syndome).

Filed under “well I be danged”! And I’ve added it to the patellofemoral syndrome tutorial, of course — mainly for the novelty of it, since fabella syndrome isn’t likely to be confused with kneecap pain.

]]>Release me!Fri, 06 Feb 2015 00:00:01 -0700https://www.painscience.com/articles/does-fascia-matter.php
https://www.painscience.com/microblog/release-me.htmlI am getting almost as fed up with the word “release” in massage therapy as I am with “toxins.”

“Release” does not (indeed, it cannot) refer to any known, specific state of soft tissue. It’s poetry, not biology. It’s massage-speak for “better in some way, hopefully for more than ten minutes.”

As commonly used, the word strongly suggests an actual change in the flesh…but this assumption derives only from vague, erratic, uninterpretable sensory cues. Most therapists say — not all of them, importantly, but most — that they can feel tissue changing texture as they work, but that could easily be misinterpreted muscle behaviour and palpatory pareidolia.

Patients may experience a kaleidoscopic array of sensations during massage, and often call it “release” if they perceive an especially significant improvement (from feeling “stuck” to feeling “relieved,” say) — but we have almost no idea what any of these sensations imply about tissue state, if anything. People also have profound shifts in sensation from a good back scratch, fervent prayer, and eating cheesecake!

]]>Make exercise as sexy as the scalpelTue, 03 Feb 2015 00:00:00 -0700https://www.painscience.com/microblog/make-exercise-as-sexy-as-the-scalpel.htmlAn excellent short opinion piece by Jørgen Jevne in the British Medical Journal about unnecessary shoulder surgeries, with broad applicability to other orthopedic surgeries. Here are some highlights (with related references):

For over twenty years, surgery has failed to provide superior outcomes compared to conservative therapy for the treatment of subacromial pain syndrome. The results are consistent and with methodology more rigorous, the differences are even smaller, as illustrated by recent systematic reviews. [Saltychev et al]

Shoulder pain remains somewhat of a medical mystery and the ambiguities are nicely illustrated by a 2009 study, which showed that a bursectomy alone had comparable effects to removing the acromion and bursa. [Henkus et al]

Surgeons have generally been reluctant to perform placebo surgery…

The few orthopaedic placebo surgeries that have been published have had discouraging results and created fierce debate within the scientific community. However, a recent systematic review does indeed show that the concept of placebo surgery is both warranted and ethically justified. [Wartolowska et al]

]]>Rupture: not as obvious as you’d think!Thu, 29 Jan 2015 00:00:01 -0700https://www.painscience.com/microblog/rupture--not-as-obvious-as-youd-think.htmlComplete hamstring avulsions — that is, complete ruptures of muscles where they attach to bones — are not necessarily obvious. According to O'Laughlin et al, they “can be difficult to diagnose acutely due to swelling and patient guarding, which may mask a visibly palpable defect and lead to delays in diagnosis.” Yikes!

In this case study, the only diagnosis was “hamstring pain” for several days, before the avulsion was finally confirmed by MRI, and surgically repaired on day 13. It’s not hard to imagine cases where the diagnosis would have taken much longer — too long.